Overview
During the pandemic, Dr Marian Messih, GP Clinical Lead at Brighton and Hove Roving GP Service, worked tirelessly to support various community settings with her specialism; advance care planning and end of life care for the elderly. The Brighton and Hove Roving GP Service is provided by IC24.

Her training and medical background
Ever since Marian qualified as a GP, she’s had an interest in palliative care. In 2007 she spent a year working at Martlets Hospice in Hove, where she gained experience providing gold standard palliative care. She then began working out of hours sessions with South East Health, which later became IC24. With this wealth of experience, she was recruited into the Roving GP Service, working one day per week to carry out urgent home visits for housebound elderly patients. Alongside this, she also worked regular sessions in care homes across the city that provided step-down beds for patients. Step-down bed facilities are for patients that are ready to be discharged from hospital but are not ready to return to their usual residence. Many of these patients benefit from a period of support and rehabilitation to return to their previous level of independence; unfortunately, some of these patients are approaching the end of their lives. During this time, Marian honed her skills in palliative care for the elderly, which includes having difficult conversations with patients and their loved ones. She strengthened her elderly care skills by attaining a diploma in Geriatric Medicine.

Experiencing the first wave of the pandemic
Back in June 2019, Marian had a frightening accident in the Alps and broke her leg. It took her a long time to recover from the injury and she returned to clinical work at IC24 in January 2020, with the pandemic hitting the UK only two months later.

“At the beginning of the first wave there was a real sense of comradery. It was really difficult as there were so many unknowns when dealing with the virus. One thing that really stood out to me, was the lack of typical symptoms in my group of patients. Softer symptoms such as decreased mobility, increased confusion or poor oral intake were more common in frail and elderly patients, than the typical cough and fever you see in younger patients.”

Many people living in care homes and step-down bed facilities have multiple long-term health conditions, and a large majority are affected by physical disability or cognitive impairment. Providing appropriate and responsive care for frail elderly people is a challenge and requires a complex, multi-faceted and personalised approach for each patient. At the beginning of the first wave, Marian looked at what was needed to provide a high quality of care for patients on a case-by-case basis. Marian ensures that each decision has the patient’s best interests at heart and collaborates with their friends and family.

“Deciding who would benefit from escalation to hospital and who should remain in their usual residence for end of life care can be extremely difficult. Fortunately, experience helps. Sometimes the best thing we can do for patients is to provide them with the comfort and care they need for the last few days of their lives. At times this job can feel more like an art than science.”

Having difficult conversations and managing the outbreak
“Before COVID-19 it was important for me to see patients face-to-face. When consultations moved to remote sessions, I knew that the medium wouldn’t lend itself easily to my work. Many patients have sensory or cognitive impairments and having these difficult conversations raises challenges that need to be assessed in person. And, although it was a relief to be able to have these conversations in person again, the added complexities of wearing masks has been hard too.”

“We all experienced a brief break in the summer months, but this last period has been the most challenging so far - dealing with the normal NHS winter pressures as well as larger COVID outbreaks in care homes. It really has been a juggling act between dedicated patient care, working with my IC24 colleagues, engaging with the wider system, and keeping up to date with rapidly updated guidance. I’m very grateful that I’ve had the continued and unwavering support from the senior IC24 management team.”

“I’ve also spent many hours in system-wide care home management meetings involving many partner organisations. These meetings bring the CCG, Public Health, community NHS trusts and local authorities together to discuss COVID outbreaks in care homes across the city. I feel as a frontline clinician I am able to offer a unique and valuable perspective.”

“I’ve also been involved in the roll out of ReSPECT across Sussex. ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) is a user friendly, straightforward way of approaching and documenting advance care planning, placing the patient’s priorities at the centre of their care. I’m a big fan of ReSPECT and in time I’m hoping it will replace the red DNACPR (Do not attempt cardiopulmonary resuscitation) forms we’re all used to.”

Focusing on one day at a time
As many people can relate, it’s been hard to remain resilient during the winter months, especially persevering with another national lockdown. Marian explains that it’s crucial to look after yourself in order to give your patients the best possible care.

“It can be hard to practice self-care and remain resilient during these difficult times, especially when many sources of support such as regular contact with family and friends aren’t as easily available. Being out in nature really helps and I’m very grateful to live so close to the sea. My main advice is to focus on one day at a time and to look after each other."

A sincere thank you to Marian for taking part. Stay tuned for the next instalment of the ‘IC24 Star of the Month’. You can find out more about our brilliant people by searching #MadeToBeBrave on Facebook, LinkedIn, Twitter, and Instagram.